39 F with viral pyrexia with polyserositis

 A 39 yrs old female farmer by occupation came to the opd with chief complaints of 

• Fever since 8 days 

• SOB  7 days back 


HISTORY OF PRESENT ILLNESS 


Pt was apparently asyptomatic 8 days back later she developed fever which is of low grade,intermittent, and not associated with  chills,rigors. 


Shortness of breath  7 days back (MMRC grade 1) which was not associated with wheezing,palpitations  sweating. 


C/o loose stools 6 days back which was of watery in consistency, non bloody, non foul smelling 


Also complains of  chest tightness,loss of weight. 


No h/o cold,cough nausea,vomiting,loss of appetite. 


HISTORY  OF PAST ILLNESS 


N/K/C/O Hypertension, DM,epilepsy, Asthma, tb, CAD 

No h/o covid 


PERSONAL HISTORY 


Diet mixed 


Appetite normal 

                 Decreased food intake  due to.                             nausea 


B&b movements:  Irregular , loose stools watery in consistency ,non bloody ,non foul smelling. 


Sleep adequate 


Allergies : dust allergy


Addictions : none


FAMILY HISTORY 

NOT SIGNIFICANT 



MENSTRUAL HISTORY 

Age of menarche   at 15yrs of age 

Cycles being regular with 5/28 day cycles 


OBSTETRIC HISTORY 

Age at marriage 17yrs 



GENERAL PHYSICAL EXAMINATION 


Patient is conscious , coherent ,cooperative. Well  oriented to time place person . Moderately built and malnourished


Pallor  absent

Icterus absent 

Cyanosis absent 

Clubbing absent 

Lymphadenopathy absent 

Edema absent 


Vitals  

Temperature  98.4°f 

PR  84 bpm 

RR  19cpm 

BP 110/70 mmHg  

Spo2 98% at RA 

GRBS 97 mg%


On 12/9/22 


Temp 98.3°f 

PR  84bpm 

RR  20cpm 

BP 100/70mmHg 

Spo2. 99% @RA



Systemic examination  


CVS- no thrill, s1 s2 heard, no murmurs  


RS - BAE+, grade  2 dyspnea

       No h/o wheezing

       Trachea central

        Adventurous sounds - crepts : b/l 


CNS - pt is conscious 

          Normal speech

          Neck stiffness -

           Kernigs sign -

          Cranial nerves intact

          Sensory system  intact

         Power 

                          Rt.               Lt

           UL.         5/5.           5/5

           LL.           5/5.          5/5



P/A - soft and non tender ,bowel sounds heard 


REFLEXES  

                 B.            T.             S.        K.       A 


Rt.             +             +             +          +        +

Lt.             +              +            +          +         + 


Plantars -  flexor


INVESTIGATIONS 




On 7/9/22


On 8/9/22











On 10/9/22



On 11/9/22












PROVISIONAL DIAGNOSIS 


VIRAL PYREXIA with polyserositis


TREATMENT 


• Plenty of fluids

• Normal diet 

• TAB  lincee 400mg/od

• Enterogeamina liquid od

• Protein x powder 2 scoops in 1 glass milk

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